Severe acute respiratory syndrome coronavirus-2-related and imputable deaths in children:results from the French pediatric national registry

Background Severe acute respiratory syndrome coronavirus-2(SARS-CoV-2)is responsible for an important mortality rate worldwide.We aimed to evaluate the actual imputability of SARS-CoV-2 on the mortality rate associated with SARS-CoV-2-related illnesses in the pediatric intensive care unit(PICU).Secondary objectives were to identify risk factors for death.Methods This national multicenter comparative study comprised all patients under 18 years old with positive SARS-CoV-2 polymerase chain reactions(PCRs)[acute corona virus disease 2019(COVID-19)or incidental SARS-CoV-2 infection]and/or pediatric inflammatory multisystem syndrome(PIMS)recorded in the French PICU registry(PICURe)between September 1,2021,and August 31,2022.Included patients were classified and compared according to their living status at the end of their PICU stay.Deceased patients were evaluated by four experts in the field of pediatric infectiology and/or pediatric intensive care.The imputability of SARS-CoV-2 as the cause of death was classified into four categories:certain,very probable,possible,or unlikely,and was defined by any of the first three categories.Results There were 948 patients included of which 43 died(4.5%).From this,26 deaths(67%)could be attributed to SARS-CoV-2 infection,with an overall mortality rate of 2.8%.The imputability of death to SARS-CoV-2 was considered certain in only one case(O.1%).Deceased patients suffered more often from comorbidities,especially heart disease,neurological disorders,hematological disease,cancer,and obesity.None of the deceased patients were admitted for pediatric inflam-matory multisystem syndrome(PIMS).Mortality risk factors were male gender,cardiac comorbidities,cancer,and acute respiratorydistress syndrome.Conclusions SARS-CoV-2 mortality in the French pediatric population was low.Even though the imputability of SARS-Cov-2 on mortality was considered in almost two-thirds of cases,this imputability was considered certain in only one case.

Assessment of left-ventricular diastolic function in pediatric intensive-care patients:a review of parameters and indications compared with those for adults

Background The incidence of diastolic heart failure has increased over time.The evaluation of left-ventricular diastolic func-tion is complex,ongoing,and remains poorly performed in pediatric intensive-care patients.This study aimed to review the literature and to provide an update on the evaluation of left-ventricular diastolic function in adults and children in intensive care.Data sources We searched data from PubMed/Medline.Thirty-two studies were included.Four pragmatic questions were identified:(1)What is the physiopathology of diastolic dysfunction?(2)Which tools are required to evaluate diastolic func-tion?(3)What are the echocardiographic criteria needed to evaluate diastolic function?(4)When should diastolic function be evaluated in pediatric intensive care?Results Early diastole allows characterization of relaxation,whereas compliance assessments and filling pressures are evalu-ated during late diastole.The evolution of diastolic function differs between adults and children.Unlike in adults,decreased compliance occurs at the same time as delayed relaxation in children.Diastolic function can be evaluated by Doppler echo-cardiography.The echocardiographic criteria for ventricular relaxation include the E wave,E/A wave ratio,and isovolumic relaxation time.Ventricular compliance can be assessed by the E/e'wave ratio,atrial volume,and Ap wave duration during pulmonary vein flow.In adult intensive-care patients,the E/e'ratio can be used as an index of tolerance for volume expan-sion in septic patients and to adjust the inotropic support.Conclusion Clinical studies would allow some of these parameters to be validated for use in children in intensive care.

Impact of time to diagnosis on the occurrence of cardiogenic shock in MIS‑C post‑COVID-19 infection

Background In multisystem inflammatory syndrome in children(MIS-C),diagnostic delay could be associated with severity.This study aims to measure the time to diagnosis in MIS-C,assess its impact on the occurrence of cardiogenic shock,and specify its determinants.Methods A single-center prospective cohort observational study was conducted between May 2020 and July 2022 at a tertiary care hospital.Children meeting the World Health Organization MIS-C criteria were included.A long time to diagnosis was defined as six days or more.Data on time to diagnosis were collected by two independent physicians.The primary outcome was the occurrence of cardiogenic shock.Logistic regression and receiver operating characteristic curve analysis were used for outcomes,and a Cox proportional hazards model was used for determinants.Results Totally 60 children were assessed for inclusion,and 31 were finally analyzed[52%males,median age 8.8(5.7-10.7)years].The median time to diagnosis was 5.3(4.2-6.2)days.In univariable analysis,age above the median,time to diagnosis,high C-reactive protein,and high N-terminal pro-B-type natriuretic peptide(NT-proBNP)were associated with cardiogenic shock[odds ratio(OR)6.13(1.02-36.9),2.79(1.15-6.74),2.08(1.05-4.12),and 1.70(1.04-2.78),respectively].In multivariable analysis,time to diagnosis≥6 days was associated with cardiogenic shock[adjusted OR(aOR)21.2(1.98-227)].Time to diagnosis≥6 days had a sensitivity of 89% and a specificity of 77% in predicting cardiogenic shock;the addition of age>8 years and NT-proBNP at diagnosis≥11,254 ng/L increased the specificity to 91%.Independent determinants of short time to diagnosis were age<8.8 years[aHR 0.34(0.13-0.88)],short distance to tertiary care hospital[aHR 0.27(0.08-0.92)],and the late period of the COVID-19 pandemic[aHR 2.48(1.05-5.85)].Conclusions Time to diagnosis≥6 days was independently associated with cardiogenic shock in MIS-C.Early diagnosis and treatment are crucial to avoid the use of inotropes and limit morbidity,especially in older children.